Objective The authors conducted a meta-analytic review of adherence–outcome and competence– outcome findings, and examined plausible moderators of these relations. Method A computerized search of the PsycINFO database was conducted. In addition, the reference sections of all obtained studies were examined for any additional relevant articles or review chapters. The literature search identified 36 studies that met the inclusion criteria. Results R-type effect size estimates were derived from 32 adherence–outcome and 17 competence–outcome findings. Neither the mean weighted adherence– outcome (r = .02) nor competence–outcome (r = .07) effect size estimates were found to be significantly different from zero. Significant heterogeneity was observed across both the adherence–outcome and competence–outcome effect size estimates, suggesting that the individual studies were not all drawn from the same population. Moderator analyses revealed that larger competence–outcome effect size estimates were associated with studies that either targeted depression or did not control for the influence of the therapeutic alliance. Conclusions One explanation for these results is that, among the treatment modalities represented in this review, therapist adherence and competence play little role in determining symptom change. However, given the significant heterogeneity observed across findings, mean effect sizes must be interpreted with caution. Factors that may account for the nonsignificant adherence– outcome and competence–outcome findings reported within many of the studies reviewed are addressed. Finally, the implication of these results and directions for future process research are discussed.

Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.

This meta-analysis assessed efficacy of pharmacologic and psychological interventions for treatment of perinatal depression. A systematic review identified 27 studies, including open trials (n=9), quasi-randomized trials (n=2), and randomized controlled trials (n=16) assessing change from pretreatment to posttreatment or comparing these interventions to a control group. Uncontrolled and controlled effect sizes were assessed in separate meta-analyses. There was significant improvement in depressive symptoms from pretreatment to posttreatment, with an uncontrolled overall effect size (Hedges' g) of 1.61 after removal of outliers and correction for publication bias. Symptom levels at posttreatment were below cutoff levels indicative of clinically significant symptoms. At posttreatment, intervention groups demonstrated significantly greater reductions in depressive symptoms compared to control groups, with an overall controlled effect size (Hedges' g) of 0.65 after removal of outliers. Individual psychotherapy was superior to group psychotherapy with regard to changes in symptoms from pretreatment to posttreatment. Interventions including an interpersonal therapy component were found to have greater effect sizes, compared to control conditions, than interventions including a cognitive–behavioral component. Implications of the findings for clinical practice and future research are discussed.

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The authors examined the relation between therapist process variables (adherence and competence) and subsequent symptomatic change in patients. Twenty-nine depressed patients were seen in 16 sessions of weekly supportive expressive (SE) dynamic psychotherapy. Change in depression from intake to Session 3 predicted higher ratings of adherence to expressive (interpretative) techniques during Session 3 but not their competent delivery. Partialling pretreatment psychiatric severity, therapists' adherence to use of expressive techniques, and previous symptomatic improvement, relatively competent delivery of SE-specific expressive techniques predicted subsequent improvement in depression. Secondary analyses addressing alternative explanations (such as the role of either therapeutic alliance or general therapeutic skills) did not change the results.

The assessment of intervention competence possesses an obvious relevance for practitioners and clinical scientists alike. It is often assessed as part of the evaluation of treatment integrity in clinical research in general, and in randomized clinical trials (RCTs) in particular. The authors first attempt to add clarity to the concept and better differentiate intervention competence from closely related constructs. Next, the authors review and evaluate the main measures of therapist competence used in RCTs, relying on this conceptual foundation to provide suggestions for future measures. The empirical literature on the relation between therapist competence and clinical outcome is then reviewed. The relation, while positive, is weaker than expected, and factors having a potential bearing on this are discussed. The authors then recommend that new measures be created and that the assessment of limited-domain competence be supplemented by explorations of global competence. Due to the potential ramifications for the field, the authors also recommend that caution be exercised in the task of operationally defining competence.

The author discusses the evidence for six basic statements that many, but not all, psychotherapy researchers adhere to: (1) The therapeutic alliance has a causal role in outcome, (2) therapeutic techniques explain patients' outcome, (3) therapists determine outcome, (4) patients determine therapy outcome, (5) randomized controlled trials (RCTs) provide valuable data, (6) data from RCTs are almost worthless. These "truths" combine to form three core conflicts: Is psychotherapy about the alliance or techniques? Does the patient or therapist determine the outcome? Are RCTs a blessing or a curse? After showing that these statements oversimplify the research of the therapeutic process, the author recommends keeping both sides of the conflict in awareness and endorses a pluralistic methodological approach for the study of both efficacy and the mechanisms of psychotherapy.

The authors examined the relations among therapeutic alliance, outcome, and early-in-treatment symptomatic improvement in a group of 86 patients with generalized anxiety disorders, chronic depression, or avoidant or obsessive-compulsive personality disorder who received supportive-expressive dynamic psychotherapy. Although alliance at Sessions 5 and 10, but not at Session 2, was associated with prior change in depression, alliance at all sessions significantly predicted subsequent change in depression when prior change in depression was partialed out. The results are discussed in terms of the causal role of the alliance in therapeutic outcome.